Looking at health care system performance: Lessons from the Commonwealth Fund survey

Sukirtha Tharmalingam, Senior Policy Analyst, Health Council of Canada 

The Health Council of Canada has been pleased to be a key contributor to the design and funding of the annual Commonwealth Fund’s International Health Policy Survey (CMWF IHP survey) since 2009. Using the data collected in these annual surveys, we released a series of bulletins under the banner, Canadian Health Care Matters that focused on different aspects of public/patient and physician perceptions and experiences with our health care system.
The 2013 survey of the general public includes about 100 questions that address a comprehensive range of issues in our health care system.  The report we released today, Where you live matters: Canadian views on health care quality , lets us compare the performance of provincial health systems with that of 10 other high-income countries.  We also compare results from the 2013 survey to the same questions asked in 2004, 2007 and 2010.  We find that Canadians’ experiences with their health care system vary widely across the country and from our international counterparts. For example, if you are in BC, you may be happier knowing that your province outperforms all other provinces in getting a same-day or next-day appointment when needed – 41% of respondents say they can. However, even BC as the best performer lags far behind the other 10 other countries participating in this survey.  In the top performing country Germany, 76% of people surveyed report they can get a same-day or next-day appointment.  Over the past decade, Canada has shown little change in this aspect of access to care – hovering around the 40% range since 2004.  This and other comparisons we present in the bulletin serve to raise flags for others to probe further into the factors that contribute to the variations and trends we see.

Looking back and moving forward

With an eye to the future, there are a few insights and learnings that I would like to share based on working with the CMWF surveys for the last four years.
 
1. Canadians have something to say about their health care system performance and it matters! 

The findings we presented through these reports definitely resonated with Canadians.  This was evident to us through the interest they generated from national and local media and news agencies (the Toronto Star) and (the Globe & Mail), report downloads from our website, references to the statistics we presented, and the plethora of patient stories the reports brought forward.
[The cost of chronic illness] [Worrying about my future] [In search of support: the importance of communication in the heath care system]

2. There are recognizable challenges and limitations to a population based survey data

There are methodological challenges we face when analyzing and reporting on results from these surveys.  Achieving perfectly consistent and comparable survey data across the participating countries and even provinces within Canada is virtually impossible. Examples of some things to consider are variations in response rates, individual interpretation of the survey questions, representativeness of the population being surveyed, or one’s ability to recall an experience. However, tremendous efforts were taken to ensure that we developed questions that were unambiguous and could offer important insights on the health care system. We also employed statistical techniques to help us improve the interpretability of the results.

3. There are recognizable benefits to participating in a cross-sectional annual international survey that assesses health system performance from the perspective of those who interact with it. 

Although self-reported measures derived from population surveys can be challenged, we need to be wary that we are not dismissing results because we think they may not be comparable. There are benefits to these survey findings and the comparative lens (international, provincial, over time) they provide us. It allows us to understand what is being achieved in other countries of similar economic size and income and provokes us to think about where there are potential gains to be made in Canada.  For example, which countries have higher performance and what policy directions and strategies do they share with us? What aspects of the health system have improved over time; which have not?

As the Health Council prepares to wind down in March 2014, we are pleased that CIHI and CIHR-IHSPR have agreed to co-lead the Canadian contributions on future Commonwealth Fund surveys. We have enjoyed the opportunity to bring forward the results from this survey in recent years and have been pleased to collaborate with the health agencies in Alberta, Ontario and Quebec to expand sample sizes in their respective provinces. The self-reported experiences of those who are in direct contact with the health care system provide a unique and vital piece of information that can help to improve the delivery of health care. I hope that this important source of information will continue to play a role in supporting decisions by health care providers, managers, and policy makers. 

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The Home First philsophy - creating safe transitions for patients from acute care to home

Caroline Brereton, RN, MBA is a registered nurse and holds an MBA from Queens University. She is a graduate of the Rotman School of Management Advanced Health Leadership Program.
A senior healthcare executive with 15 years of leadership experience, Caroline became Chief Executive Officer of the Mississauga Halton CCAC in May 2010. Caroline has a vision for a system that is fully aligned to support the needs of patients.

The growing population of seniors across the province will continue to increase pressure on the health sector to provide health care at home, including community services to help seniors move from  hospital to home following acute treatment and programs to help residents remain safely at home for longer. We feel it acutely in our Mississauga Halton communities of South Etobicoke, Mississauga, Oakville, Milton and Halton Hills.  We experienced one of Ontario’s highest growth rates in population, a 12 per cent increase in population from 2006 to 2011.  The Mississauga Halton region is the second fastest growing population of seniors in Canada (projected 32.3 per cent increase in 75 to 84 year-olds and 71.1 per cent increase in seniors 85 and older, by 2013).

 In 2009, anticipating population growth, the Mississauga Halton CCAC, was the first to launch the Home First Philosophy. In collaboration with our region’s hospitals, Trillium Health Partners and Halton Healthcare Services, funding was provided by the Mississauga Halton LHIN.

The philosophy embodied our objective: to slow the growth of alternate level of care (ALC) rates in hospital, while at the same time supporting the province’s goal to increase access aging at home. It was ambitious; the number of ALC days nearly doubled from 9.3 per cent in 2007 to 17.5 per cent in 2008.
The Home First Philosophy was the foundation for a new suite of Wait at Home services and that was our approach to tackling the growing ALC rate. It is a team-based philosophy that promotes safe and timely care, services and supports, which helps to meet the health care needs of patients and families in the most appropriate setting. The Home First philosophy recognizes that the home environment is the best place for recovery and supports people in returning to their homes from hospital wherever possible. It also provides the necessary services to help older adults maintain their continued independence in the community.

Challenges and Hurdles
This new philosophy necessitated changes in workflow, culture and communication. When we introduced it to our patients, staff and partners, it was a huge culture shift in health care thinking for families and physicians.  Traditionally, patients applied to long-term care homes from the hospital.

Physicians were concerned about safety and risk to patients leaving hospital and returning home. We helped physicians understand the quality of care provided in the community through the Mississauga Halton CCAC. We explained our approach and introduced new services that would ensure patients, even those with complex care needs, would be safe at home while they applied for long-term care or recovered and realized they could stay at home safely with services from our CCAC.

Better Outcomes
Together, with our partners, we drove better results and we continue to bring proactive change to the health care system. With innovative efforts and focused teamwork, the consistently low ALC rates in Mississauga Halton is evidence of system integration as a key mechanism for delivering the right care, in the right place, at the right time.  In fiscal 2012/13 our ALC rate was seven per cent and 6.3 per cent in the previous year. This means that 93 per cent of hospital beds in our region were available to patients needing hospital care.

Staying in hospital after surgery or treatment is not in a patient’s best interest. There is an increased risk of infection; and patients become less independent the longer they stay in hospital.The Home First philosophy is an enormous cost savings to our health system. Every ten per cent  shift of ALC patients from acute care to home care results in a $35-million saving.  And most importantly, it provides better outcomes for patients where they are happier and more comfortable in a familiar setting and they tend to recover more quickly.
Recently, a patient’s son, who is caring for his 83-year-old father at home, told us:  “The Mississauga Halton CCAC made it so simple and smooth. You take care of everything – personal support workers, nurses, occupational and physical therapists, medical equipment and supplies.  They brought the hospital to our home.  Now my father is safe and secure, and getting the quality of life he deserves.  My father belongs here.  Without you, we could not do it.  It would have been impossible. It is a blessing to have my dad here.”
However, if a patient and family decide that long-term care is the right place to be, we help them through the process from beginning to end. We start by directing them to our long-term care website – http://mhccac-ltc.com/ –which provides information about wait lists and costs, as well as a virtual tour of our region’s 27 long-term care homes.

At the Mississauga Halton CCAC, we look at health care differently. We recognize health care at home is not the future; it is the reality of health care today.

*Watch the video on the Home First program, part of the Health Council's Wait Times video series.

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Something more must be done to address the health challenges of Aboriginal seniors

Dr. Catherine Cook, councillor with the Health Council of Canada, is also a family physician, researcher, health care manager, and Métis. She currently has a joint role with the University of Manitoba and the Winnipeg Regional Health Authority. At the University of Manitoba, Dr. Cook is the Associate Dean for First Nations, Métis and Inuit Health in the Faculty of Medicine and is currently a leader of the newly established Section of First Nations, Métis and Inuit Health in the Department of Community Health Sciences, Faculty of Medicine. 

 First Nations, Inuit and Métis seniors are indeed Canada’s most vulnerable population. We know that they do not receive the same level of health care as non-Aboriginal seniors. Interviews with key stakeholders, literature searches and consultations across Canada, undertaken by the Health Council of Canada during the winter and spring of 2013, confirmed some glaring facts:

• Access to care is an issue. Most need to travel to urban areas for anything beyond the most basic care, with significant disruption to their lives.
• They often fall victim to the vagaries of government policies at the federal and provincial levels as to what costs are covered by whom and who is eligible for what services.
• There is little or no communication and coordination between services supported by governments, regional health authorities, and communities.
• Many Aboriginal seniors don’t have the same level of care in their communities as non-Aboriginal Canadians, so their health conditions can become more severe, increasing the amount of care they need. 

The situation is exacerbated by the impact of colonization, residential school experiences and by determinants of health such as poverty, poor housing, racism, language barriers, and cultural differences. Geographic isolation also comes into play: Aboriginal seniors are also more likely than younger generations to live in rural and remote communities where the majority of the population is Aboriginal, and where they can be connected to their culture. The result is that they have more complex health needs and are often living in regions where it is more challenging and expensive to provide care.

The Health Council report provides context on these challenges and why it is important to provide additional support and seamless care to First Nations, Inuit, and Metis seniors.  Without this, an already vulnerable population is at even greater risk. This issue that requires immediate attention by Canadians and governments alike.
However, there are some promising examples from across Canada where governments, health regions, and Aboriginal communities have formed partnerships to improve health care for Aboriginal seniors. I invite you visit www.healthcouncilcanada.ca/innovation to read about these practices. 

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Community health aides help with nursing shortages and cultural safety

Tina Buckle, Community Health Nursing Coordinator, Nunatsiavut Department of Health and Social Development

In Nunatsiavut, we use Community Health Aides to support nursing staff in remote communities. We have a challenge recruiting and retaining nurses, and the aide position has allowed us to manage with fewer nurses. It’s a model that borrows from Labrador in the past and from Alaska in the present, where community health aides, local people from the community, help to deliver health care in remote communities.  In Nunatsiavut, the community health aide has a role in both public health and home and community care.

In the Home and Community Care program, the community health aides function as the nurses’ “right hands.” They manage the home support workers, go with the nurse to client visits as needed, order equipment and supplies, schedule appointments, sterilize equipment, complete month-end reports, and anything else that doesn’t require a nurse to do. The nurse is then able to concentrate on direct client care. The aides also do independent home visiting to support the programs, both when a nurse is in town and when the position is vacant.

Just as important, the aides are the cultural advisors to new nurses. They are so trusted in the community that any new nurse is immediately accepted if accompanied by the aide. From a senior care perspective, the aides have the ability to spend more time with seniors than the nurses do; also, they have personal connections and speak the language. We have also given the community health aides tours of the regional health and long-term care centres in Happy Valley-Goose Bay so that they can describe them to seniors and their families and help them become comfortable with the transition.

It’s hard to quantify or even to put into words the value of community health aides —essentially, we would not be able to deliver care without them and clients would not be as willing to receive care. It’s hard to understand why this model hasn’t spread to other parts of the country, particularly since it’s also well known in Alaska. I think there’s almost a strange fear that by allowing this kind of practice we’re encouraging people to be community health aides instead of going into the health professions, but that’s not what it’s about at all. There is an incredibly valuable role for these people at the community level that no one else can fill like they do.

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One home care program for everyone: Bella Coola, British Columbia

Glenda Phillips, Manager, Home & Community Support, Bella Coola General Hospital

In my community, Bella Coola, we have a fully integrated home and community care program situated in a new health centre on-reserve that is used by everyone in the community, whether they are First Nations or not. But it wasn’t always that way.

Bella Coola is a geographically remote community with limited resources. I was the federal health nurse there for years, until I went back to university. When I returned, I was hired by the province to set up home care in the region. I saw that people on-reserve weren’t getting services. There was no structured home and community care program, and no integrated service delivery model between the services offered on-reserve and those offered by the province. We had five long-term care beds in a small community hospital, and no assisted living. Complicating the situation were factors such as budget constraints, nursing shortages, and a lack of clarity around staff roles and responsibilities.  

We wanted to give people equal access to care and the option to remain at home as long as possible—not just in their community but in their own homes. We needed an integrated care program to support this and we wanted to build capacity for culturally sensitive care.  We started the planning by going to the Chief and Council of Nuxalk Nation and saying, “Why don’t we work together and set up a program for everyone?” Then we went out on the road talking to the community, conducting a community needs assessment, and meeting with the many different organizations and government representatives who needed to be consulted.

In the end, we made just one home care program where there had been two (the province’s program and the federal FNIHCC program). There is no new money; we pooled our funding streams to work around budget constraints. And by coming together, we expanded our capacity and flexibility. For instance, there is a four-hour cap on the number of hours of home support we can provide to a client in a day. But if a couple of more hours a day means that the client can stay in the community and in their home, then we provide more hours. It’s good quality care, and it’s cost effective for the system.

Other communities have asked us how they can do similar types of integrated programs. We tell them the standards of care are going to be the same—how you do your assessments, how you clean your tools, how you chart—but how you deliver the care might be a little different because of the culture in your community. You have to know the community. 

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Supporting Métis seniors and families

Wenda Watteyne, Director of Healing and Wellness, and Dr. Storm J. Russell, Senior Policy and Research Analyst, Métis Nation of Ontario

Few Canadians realize that one third of all Aboriginal people in Canada are Métis, and that the Métis population is older compared to other Aboriginal groups. From our research, we know that many of our seniors are experiencing significantly higher rates of chronic disease and other complex conditions compared to non-Métis Ontarians. Métis people also fall under a different legislative and regulatory structure than do other Aboriginal groups, and do not have access to programming supports such as the Non-Insured Health Benefits program that is available to many Aboriginal peoples. Many also live in remote and rural areas, where access to services and supports can be limited. For Métis seniors living on limited incomes, things like transportation to see doctors and specialists, as well as having the means to fill expensive prescriptions, can also serve as barriers to care.  Finally, access to culturally safe care can be a challenge for older Métis citizens.

It is for all these reasons and more that the Métis Nation of Ontario (MNO) provides programs and services at the community level. Situated in 18 Métis communities distributed across the province, MNO community centres serve as important cultural and service hubs that link our Métis citizens to each other, as well as to health services and supports in their local areas. The MNO community centres are especially important in providing our Métis seniors with the kinds of culturally grounded services and supports they need, along with help in accessing medical services. Some of our MNO centres also offer specialist services such as foot care clinics for seniors and other Métis people suffering from diabetes. MNO community centre workers also much in the way of outreach to Métis seniors in need of assistance, visiting their homes to help with things like meal preparation, house maintenance, and other tasks of daily living, while at the same time providing that important cultural connection and support. Through the MNO Community Support Services program we are also able to provide transportation services to help Métis seniors travel to and from their medical appointments.

For the many Métis seniors and other community members who are suffering from significantly higher rates of chronic diseases and conditions, MNO community centres provide a place where they meet with other Métis community members and receive much-needed support and care, and get help in linking to essential services and programs in the broader community. The centres also provide a haven for culturally safe community care. 

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Minding the Gaps in Quality Improvement in Canada

John G. Abbott

John G. Abbott is the CEO of the Health Council of Canada

What can Canada gain by upping its investment to advance the health quality improvement agenda? And, in what areas should it invest?

A lot, in my opinion; and the focus needs to be on increasing the capability and capacity of our system and its leaders to deliver transformative change. 

This week, the Health Council of Canada held a national symposium on quality improvement under the theme: Towards a High-Performing Health Care System: The Role of Canada’s Quality Councils. 

Dr. Ross Baker

Over 200 senior leaders from across the country converged to talk about health system performance measurement and reporting, and building system capacity for quality improvement.  It was clear that there is no ‘one size fits all' when it comes to performance measurement or reporting and each jurisdiction with a quality and/or patient safety organization (there are seven in total) have adopted approaches that are working for them. So what are the gaps in Canada’s current quality improvement approach that need to be closed?

The first gap is the absence of a burning platform for transformative change so that quality improvement is embedded in everything we do in health care. Are health leaders and Canadians themselves convinced that we need to improve the quality of the care being delivered in each hospital, clinic and doctor’s office in this country? The evidence says we need to, but is that enough to make the case?

Panel on Building System Capacity for Quality Improvement

The second gap or challenge is treating QI as an add-on. Shouldn’t our health system encourage all its leaders to begin their day with the question: what have we got to do today to ensure all our activities deliver safe and appropriate care for our patients; and end their day by asking:  how do we know that we achieved this objective? If QI is its own silo, we are not going to achieve transformative change in any setting.

The third gap relates to resources. We need to increase the level of investment in resources to successfully design and manage a QI agenda. We need to train people at the front lines and in the back rooms to think as one, using a common language around performance improvement.  We need to continually support the work of quality councils in this country who in turn are aligning their activities in support of the health systems that they both monitor and engage on quality improvement initiatives.

A fourth gap is not appreciating the magnitude of managing complex system change.

A fifth gap lies in the area of technology and information sharing. We need to leverage the use of today’s technology to collect data and share information about system performance and patient outcomes in a consistent and timely way that can be used by all parts of the system to improve the quality of care.

No one organization or system has all the answers to addressing these gaps. All in all, we need to collaborate within and across organizations and jurisdictions to build capacity and capability in all these areas.  The Health Council’s report on the proceedings of its event will cover these points in greater detail and will be released on December 16, 2013 at www.healthcouncilcanada.ca.

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